PEPFAR Haiti Country Operational Plan 2017 (COP 2017) Strategic Direction Summary May 2017
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PEPFAR Haiti Country Operational Plan 2017 (COP 2017) Strategic Direction Summary May 2017 1 | P a g e Table of Contents 1.0 Goal Statement 2.0 Epidemic, Response, and Program Context 2.1 Summary statistics, disease burden and epidemic profile 2.2 Investment profile 2.3 Sustainability Profile 2.4 Alignment of PEPFAR investments geographically to burden of disease 2.5 Stakeholder engagement 3.0 Geographic and population prioritization 4.0 Program Activities for Epidemic Control in Scale-up Locations and Populations 4.1 Targets for scale-up locations and populations 4.2 Priority population prevention 4.3 Voluntary medical male circumcision (VMMC) 4.4 Preventing mother-to-child transmission (PMTCT) 4.5 HIV testing and counseling (HTS) 4.6 Facility and community-based care and support 4.7 TB/HIV 4.8 Adult treatment 4.9 Pediatric Treatment 4.10 OVC 4.11 Addressing COP17 Technical Considerations 4.12 Commodities 4.13 Collaboration, Integration and Monitoring 5.0 Program Activities for Epidemic Control in Attained and Sustained Locations and Populations 5.1 Targets for scale-up locations and populations 5.2 Priority population prevention 5.3 Voluntary medical male circumcision (VMMC) 5.4 Preventing mother-to-child transmission (PMTCT) 5.5 HIV testing and counseling (HTS) 5.6 Facility and community-based care and support 5.7 TB/HIV 5.8 Adult treatment 5.9 Pediatric Treatment 5.10 OVC 5.11 Establishing service packages to meet targets in attained and sustained districts 5.12 Commodities 2 | P a g e 5.13 Collaboration, Integration and Monitoring 6.0 Program Support Necessary to Achieve Sustained Epidemic Control 6.1 Critical systems investments for achieving key programmatic gaps 6.2 Critical systems investments for achieving priority policies 6.3 Proposed system investments outside of programmatic gaps and priority policies 7.0 USG Management, Operations and Staffing Plan to Achieve Stated Goals Appendix A - Prioritization Appendix B- Budget Profile and Resource Projections Appendix C- Tables and Systems Investments for Section 6.0 3 | P a g e 1.0 Goal Statement The primary goal of the PEPFAR Haiti program is to achieve epidemic control in Haiti by supporting a data-driven response that leads to a reduction in new infections and AIDS-related mortality. This goal will be achieved through implementation of targeted testing approaches-- including index case contact tracing--improved retention on treatment, and expansion of multi- month scripting, community drug distribution, and rapid pathway for stable patients. Additionally, using sex and age disaggregated data, the team will focus on scaling-up HIV clinical and community services and strategies that have demonstrated the most impact. The COP 15 Annual Program Results validated the geographic pivots that refocused the program on 20 priority districts out of a total of 42 districts. This prioritization will largely be maintained in COP17. The Ministry of Health’s (MOH) National AIDS Control Program (PNLS, French acronym) has fully rolled out the Test and Start approach, as well as revised the national guidelines to adopt WHO recommendations. For COP17, the team will focus on Same-Day Initiation and the required dialogue with MOH and PNLS to create a policy environment where this can be implemented. A new focus for the PEPFAR team will be an expanded Orphans and Vulnerable Children (OVC) portfolio and additional programming for girls 9-14 that are similar to activities in countries implementing the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) program. These interventions will be focused in districts with high rates of gender- based violence (GBV) and where women and girls under 24 are being diagnosed with HIV at a higher percentage than the national prevalence (Cap-Haitien, Dessalines, Saint Marc and Port-au- Prince). We will strengthen case management to ensure that the beneficiaries receive multiple, “layered” services. We will conduct size estimates, partner mapping and GBV services mapping to ensure a data-driven program. A major challenge for the PEPFAR program is patient linkage to and retention in care (PLR). In COP16 the team began the implementation of a unique patient identifier using biometric coding (BC); BC, coupled with the use of mobile health technology and positive peer navigators, allows for micro-targeting of services, such as community drug distribution. This will improve PLR amongst the general and priority populations. BC analysis also identifies silent transfers, tracks “medical shopping”, reduces Loss to Follow-Up (LTFU) and helps us determine the precise number of patients on ART. Currently, 70,000 patients have received a BC and implementation will be completed during COP17. Furthermore, in COP15 the program initiated the roll out of viral load (VL) testing. By the end of COP16, the program plans to have VL for 100% of patients with at least six months on ART. We also plan to report on the proportion of ART patients who have achieved viral suppression. To support our COP17 programming, PEPFAR Haiti is focusing on addressing stigma-related barriers through our civil society dialogue and funding, in collaboration with UNAIDS, to conduct the first ever Stigma Index Survey in Haiti. Finally, to ensure sustainability of these investments, the PEPFAR Haiti Team continues to engage with the newly-inaugurated Haitian Government for increased funding for the national HIV/AIDS program. 4 | P a g e 2.0 Epidemic, Response, and Program Context 2.1 Summary statistics, disease burden and country profile Haiti is a low-income country with a gross national income (GNI) of $810 per capita (World Bank 2015) and a gross domestic product (GDP) of $818.3 per capita (2015), which makes it the poorest country in the Western Hemisphere. An estimated 58.6% of the country’s approximately 10.8 million people live on less than one dollar a day and cannot afford the higher quality healthcare provided in private clinics (UNDP, 2014). Haiti’s estimated 141,269 people living with HIV (PLHIV) (Small Area Estimates, OGAC 2015) constitutes the greatest burden of HIV/AIDS in the Caribbean region; this is exacerbated by the highest incidence of tuberculosis (TB) in the Western Hemisphere. Haiti has a generalized HIV/AIDS epidemic with most transmission occurring from heterosexual sex and marked by higher prevalence rates in major cities. However, the last Integrated Biological and Behavioral Surveillance (IBBS, 2014)Survey has shown that there are other drivers of new infections such as unprotected transactional and commercial sexual activities as well as unsafe sexual practices among men who have sex with men (MSM). The widespread practice of multiple concurrent partnerships and the inequitable social conditions of women and youth are also considered among the key enablers of HIV transmission. Though the overall prevalence remains stable, women and youth showed a higher prevalence than men in the last Demographic and Health Survey (DHS) (2012)1. There is a severe shortage of health workers, low retention of nurses and doctors, and gaps in services across all levels of the health system. Furthermore, the country’s health infrastructure has not kept pace with Haiti’s population growth from 7.5 million people in 1993 to 10.5 million in 2014. The January 2010 earthquake compounded the already difficult development situation, destroying and damaging much of the previously existing physical infrastructure (including 30,000 commercial and government buildings) and resulting in an estimated 240,000 deaths and 300,000 injuries. Included in this large-scale human loss were untold numbers of civil servants, health professionals, medical and nursing students. Moreover, the country is still recovering from one of the largest cholera epidemics in history with more than 800,000 suspected cases reported since its onset in 2010; including over 350,000 cases in 2011 alone (DELR, February 2016). Also, in the Hurricane Matthew affected areas, service provision for 12,000 PEPFAR patients was affected. The country is currently in transition following the political turmoil surrounding the presidential election and the national currency (Haitian Gourde/HTG) has lost nearly one third of its value during the last year alone; 68.30 gourdes are now needed for 1USD compared to 43.75 gourdes in 2015. This has led to decreased buying power for most Haitians and has led to a spike in attrition rates for the PEPFAR Haiti’s Locally Engaged Staff. However, the DHS data from 2006 and 2012 indicate that HIV prevalence among adults (15-49 years old) in Haiti has remained stable at 2.2%, suggesting that a successful treatment and prevention program is keeping alive those already infected while curbing transmission at a population level. As of October 2016, over 82,000 individuals were receiving antiretroviral treatment (ART) nationally, representing approximately 58% of the estimated number people living with HIV. Over 80% of all pregnant women were tested for HIV; and of those identified as 1Cayemittes M, Placide F, Barrere B, Mariko S, Severe B. Enquete Mortalité, Morbidite et Utilisation des Services Haiti 2012. Calverton, Maryland, USA: Institut Haitien de l'Enfance et ORC Macro; 2012 5 | P a g e HIV-infected, 90% received ART. PEPFAR has been instrumental in scaling up HIV services, while building MSPP capacity to sustain the HIV response over the long term. The support to the MSPP has enabled the on-going and timely updating and alignment of national clinical guidelines with international normative guidance. Of note, the MSPP adopted Test and Start in 2016, which resulted in a dramatic increase in the number of HIV-positive persons who initiated lifelong ART. Through its regional and local units, the MSPP has also been able to enforce application of norms via training for those actively engaged in community mobilization, promotion, and regulation of services. The major geographic shifts and technical pivots in the PEPFAR Haiti portfolio, undertaken during FY15 and FY16, have allowed for a better response to the unevenly distributed HIV disease burden among the different sub-national units (SNUs) in the country.